RESPONDING TO MALNUTRITION a ts aNDoctors without Borders/ Maacng Sane Fontes USA arnew sper MO Un Krank ME 85, OP loko Pm Mate er Alle, MD Joraban Fer 0 foceces Goes ry An Hops MO stam Stet, MD Meena tore on Bork MD, PH Veto Bjorklund ED Shypon Pach Balt OP over Bookman Crate rit Agcy kamleenCatare ‘ales Fond Moraga, LE yale, Ee Iyer ron, Rowe & aw? sian its Carick Utey aren Gorse mito Us Hoodauarors Nw Yr NY 10001800 ‘ets quate nenslete Seat ends and ‘pparter of Dctrs Miho Borders/ Médecine San Fontes (SF. As apni, mera, ranprot re 9nznon, MSF careers ‘recs eet cts war nase eg Doctors thst Borders recon ae onpra, hasbeen wer Sesin SOC the trl even Cove, corer eat e ulster towed tym, ae Mecsas Der: CoDs Conmuneton Ori Jen 8 el Cat Hic, rene Dosa Cover shot: Ehiopa 2008 Fagos Durore HUMANITARIAN ACTION HUMANITARIAN ACTION Dear Friends, When Doctors Without Borders/Médecins Sans Frontiéres (MSF) speaks out pul alvways based on what our medical teams have witnessed first-hand, Our action alone can never be enough to redress the injustices, atrocities, or neglect that bring patients to our clintes. But there are times when we believe our experience and medical perspective can help move others to rethink or scale up their activities to better assist the most vulnerable people in a crisis. ‘That is why we co-hosted an international symposium on nutrition with Columbia University In New York in September of this year, We brought together almost 400 nutrition experts, policy makers, representatives of leading UN and aid agencies, and community leaders from around the world. We asked: given recent adyances in our understanding and treatment of childhood malnutrition, what ‘can we now do for the 20 million children around the world suffering fram. ‘malnutrition In its severest forms? And can we prevent children reaching this life-threatening condition to hegin witha condition that we see only too often in our hospitals and clinics? ‘Asa medical humanitarian organization, our concern is always for those most at risk. In addition to confiet-related emergencies, malnutrition prim: affects infants and young children strugaling to survive in malnutrition “hot- spots” around the world where itis a chronic, ongoing, and seasonal problem, ‘This is what we are seeing in Ethiopia today, where our teams are treating tens of thousands of malnourished children in centers throughout the south of the country. ‘The symposium revealed a growing and encouraging consensus to put infants and young children first. children receive the right balance of nutrients between the ages of 6 months and 2 years, they can avoid severe malnutrition and the long-term consequences of chronic mainutrition, which include stunting ‘and poor educational development, To receive those nutrients, they must have animal-source foods, such as milk or eggs, in their diets. We must stop the current practice of sending substandard food aid to people in crises and send Instead foods that meet the nutritional requirements of the youngest children, When our medical teams encountered the pandemic of HIV/AIDS in our clinics, ‘we successfully challenged the complacency that said it was impossible to treat people with HIV/AIDS in developing countries. Today we are challenging a different kind of complacency, one that has allowed too many young children to suffer-or die-from what is a treatable and preventable disease. ‘Thank you for your continued support. Its thanks you that we at MSF are able to continue to bring medical care to tens of thousands of malnourished children, ‘and to speak out on thelr behalf. Sincerely, Nicolas de Torrenté, PhD Executive Director, Doctors Without Borders/Médecins Sans Fronti¢res (MSF)MSF Responds to Severe Malnutrition In May, Doctors Without Borders/ ‘Médocins Sans Frontiores (MSF) emergency teams found extremely high ‘numbers of children under age five who \were severely malnourished in southern thiopia. By May 13, MSF had begun ‘an emergency nutritional interv that continued to grow along with the increasing numbers of patients. n Four months later, MSF was operating, about 60 nutrition centers for pationts with severe, life-threatening malnu- trition—several centers with the Capacity to treat those also suffering from additional, complicating factors such as malaria or pneumonia, And teams were expanding operations t0 include outpatient feeding sites for ‘moderately malnourished children and their families, As of late September, MSP had treated 28,000 severely malnourished and 21,000 moderately malnourished patients. The nutrition situation in some areas had started to stabil ‘meaning the numbers of malnourished patients admitted into feeding pro grams had plateaued or had begun to decline. But that wasn't the case everywhere. In Tunto town, in the Southern Nations and Nationalities People’s (SNNP) region, the MSF team was still having days when 2,000 hungry people were lining up outside the clinic doors. Bthiopia is no stranger to mainutri- tions millions of people here receive {ood aid routinely, when itis accessible, Le Peope lineup at an MSF nutrition centrin Tonto, Southern Nations and Nationals People’s region. xmiopia 2008 Are Y2ebe/ AS gn nShasheree, MS sta ret a nia for malnoureherent igi 2008 lena Tora/ MSE But, a combination of economic and agricultural factors has made this year's levels of under-nourishment reach rare heights. This can be seen ‘throughout the Oromiya and SNNP regions where MSF nutrition centers have distributed 3,000 tons of food to 40,000 malnourished children and families, ‘Zamane,a mother in the SNNP region ‘who came to the MSF clinic in Tunto, watched her child die only two days before. She was there to try to get her surviving two-year-old into the nutri- tion program, “My husband is a farmer,” says Zamane. "He grows maize and ginger. ‘Maize Is for the family; ginger is to sell, With the income of ginger sales, ‘we normally can buy some aclditional ‘maize from the market. But this year, the price of ginger is very low andl atthe same time, the price of maize has risen and has become too expensive. It hhas become difficult to buy maize to feed the family” The rates of severely malnourished children reached approximately 11 percent andl even 15 percent ofall children under age five in some areas, of the SNNP region; nutrition inte ventions should be started when the rate reaches 3 percent. An unusually large number of older children and adults are also being admitted to the program, another sign that the nutri tional situation this year was more serious than previous years. Forty- year-old Iwados, a farmer, came to the MSP center in Tunto after becoming severely malnourished and unable to help provide for his six children, He ‘was admitted to the outpatient pro- gram where he received therapeutic food three times a day and was given food rations to share with his family. “Without these rations, Til have noth ing to eat,” Twadlos said, “Before, we could buy food at the market, but the prices have risen too much. Two times received 50 kilograms (110 pounds) rl EMERGENCY DESK - SOUTHERN ETHIOPIA of food aid from the government, but you know It’s not enough for a family as big as mine. I hope that with the help of God, future harvests will be better and my tife will improve. “JUST THE TIP OF THE ICEBERG” Every morning this summer, MS staff in southern Ethiopia found long, lines of people, sometimes up to 2,000, waiting outside the clinies. When the rains came, people stood grimly outside, many barefoot and shivering, some having come from distant regions where there is litle if any aid. MSE ‘medical staff performed “rapid screen- ings" with a MUAC, a medical tool that ‘measures the circumference of the patient's mid-upper arm and indicates, Whether he or she is malnourished or in danger of malnutrition. “The patients in MSF's care are just the tip of the iceberg,” said Rosa Crestani, MSF emergency coordinator in southern Ethiopia. Other aid organ-Wations are also in the region, working to meet the hhuge needs that still exist. “But many others are suffering. They have exhausted their food stocks, and right a Southam igi USF was operating sperximataly (rere an SAP region at the height bf the emereeney. ss Centers ne opened snd closedinaifernt areas depending on the changing nee. ‘SOURCE: OCHA now they depend totally on food aid brought in from elsewhere.” At the start ofthis intervention, MSF's strategy was to treat only the most severely malnourished. These patients are given therapeutic, nutrient-rich, read 4o-use fod nil they are stabilized, But preventative measures also are necessary to have any impact on peaples’ health and prevent moderately malnourished people from getting ‘worse, In mid-July, MSF began setting, up outpatient feeding centers for ‘moderately malnourished children and thelr families, where they receive biweekly food rations of blended fortified flours and cooking oil, This is not the optimum product, but it was the only option available. In Siraro district, a comprehensive approach that includes therapeutic feeding and targeted food distributions had a ‘measurable impact: over four weeks in July and August, the numberof patients in MS's pro-grams decreased from 1,251 0 971. While things seem to be improving in ‘many places where MSF has been treating malnourished pationts, the situation varies widely area to area due to variations in climate and rain- fall; and food costs remain prohibitively high, MSF teams continue to work in southern Ethiopia and are adapting their activities according to people's needs, Left tog al photos Ethiopia 2008: ‘SFrangois Gunan MSF Frangoi Dumont / MSF; [SFraneason Zalns© Anne Y2006/NSFEMERGENCY DESK - HAITI MSF Assists People Hit by Successive Storms Between August 16 and September 1, Haiti was ravaged by Tropical Storm Fay, Hurricane Gustav, Tropical Storm Hanna, and Hurricane Ike, On September 4, a Doctors Without Borders/Médecins Sans Frontiéres (MSF) emergency team of medical staff, logisticians, and water and sanitation experts began arriving in the northwestern city of Gonatves, which had been particularly hard-hit. “Its a moss~it’s not a town any more, it’s really a mess, sald Max Cosci, head of MSF's emergency response. Areas of Gonaives and other parts of the country remained inac- cessible long after the initial flooding. As the storms and rains continued, flood waters forced people to live on the roofs of buildings with no access to food, clean water, or sanitation. Others flacked to an estimated 150 overcrowded shelters and often lacked basic needs there, as well When the first MSF team arrived, health centers in Gona- ives were not functioning, and the team began cleaning out Rabouteau Health Center, where MSP worked in 2004 after ‘Tropical Storm Jeanne. Even before the team found a place 0 work, however, the needs were obvious. “While we were looking for a suitable place, people started coming to us with thelr friends and family who had been injured in the storm,” Cosci said. “They were opening the doors of the ambulance and just putting in people with fractured limbs ‘and open wounds.” The following day, the MSF team performed 110 consul- {ations, (reated 49 injured people, and carried out 16 surgical procedures. When MSF medical staff had treated the majority of the wounded patients, they began to see people with conditions related to the dirty water that flooded large parts of the town, such as skin dis respiratory infections, and diarrhea ‘As soon as they received water sanitation equipment, MSF staff established several clean water points in Gonatves, and by late September they were providing 350,000 liters of water per day to approximately 150,000 people or half the city’s population. Staff filled wator bladders and trucked them into areas without access to clean water, ‘though the logistles of getting into some of the storm- affected areas were extremely challenging, MSP also began holding mobile clinics, conducting consul {ations at the crowded and often unhyslenic shelters, “One of the big problems is that there are no lavatories; they've been washed away," said Cosci, “We cannot dig latrines bocause the ground is too waterlogged. We can only dig Jatrings in the small part of town that’s dry, but people will, ‘not cross the entire town to go tothe toilet.” As of late September, there were about 116 MSF staff in Gonaives, and medical teams had performed more than 2,300 consultations through the Rabouteau Health Center ‘and mobile clinies. In cooperation with the Ministry of Health, MSF opened a referral hospital in Gonaives for the ‘treatment of more severe cases. Although the floodwater had receded, medical staff were concerned about what the future would hold, “We're starting to see things that really ‘worry us, like bloody diarrhea,” Cosci said, “which could be the first sign of an epidemic in town.” MSF was also monitoring food security, which was already precarious before the storms, and treated some cases of malnutrition, During exploratory assessments in areas outside of Gonalves, MSF on September 30 reached Mamont, a town in the Arbonite region with a population of 17,000 who had been ‘completely isolated for four weeks since the storms. The town was partially submerged, its roads cut off from major towns, and the residents were without clean water, food or medical care. MSF began providing emergency assistance in Mamont and called for other organizations to assist as ‘well. On October 13, MSF denounced the ineffective response of international aid agencies in the areas of shelter and nutritional assistance. In the preceding days, some 10,000 people in Gonaives were forced onto the rooftops of their floouled homes when authorities closed IDP shelters. USF stat oid robin Gonaives. Ht 2008 © Francis Saran MSF EMERGENCY DESK - HamFamine and Ideology “Famine we see on our TV screens from time to time is all the more intolerable because it seems a vestige of a long-ago age. But this ts far from the case. During the 20th century famine caused as many deaths as did conflicts between nations. How many of us, indeed, are aware that one famine in Ukraine and the Northern Caucasus alone killed as many peasants as all the combatants killed during Wortd War I?" From the chapter “Famine and Ideology” in From Ethiopia to Chechnya: Reflections on Humanitarian Action, 1988-1999, by Francois Jean Doctors Without Borders/ Médecins Sans Fronti@res (MSF) recently published From Ethiopia to Chechnya: Reflections on Humanitarian Action, 1988-1999, a collection of essays by Frangois Jean (1956-1999) translated by Richard Swanson. Jean contributed enormously in the feld and at headquarters to the evolution, and direction of MSE for nearly two decades. After joining MSF in 1982 to establish medical and surgical projects in war-torn Lebanon, he went on to oversee emergency medical interventions in a variety of countries, including, Chad, Pakistan, Sudan, and Chechnya. Throughout his time with MSP, Jean \rote prolifically about the difficulties and challenges faced by humanitarian aid workers ina shifting political landscape. AA MSE eld works oraines the bodies of famine Victinsin 1985. Ethiopia WAS EMSF Phot sures fhe oy of Feng Jaan Learn more about Francois Jean; read From Ethiopia to Chechnya: Reflections on Humanitarian Action, 1988-1999 online; and order the book atSITUATION REPORT - YEMEN Dangerous Migration: Somali and Ethiopian Refugees Risk Everything to Leave Every year, thousands of Somalis and in Yemen, Alfonso Verdi. To avoid were thrown overboard, among them Ethiopians risk their lives crossing _detection, when they get clase to the two children. In order to intimidate us, the Gulfof Adon to Yemen, Hoping Yemen shore, the smugglers often they beat us heavily with thetr belts. toescape the conflict and extreme force the passengers to Jump out of One of the smugglers threw petral on poverty in their own countries, these the boat into deep water, whether _us and showed off his lighter” desperate passengers are regularly they can swim or not abused and sometimes killed by (MSF has been working on the southern the brutal smugglers they pay to get. “They pointed at us with their shore of Yemen since September 2007 them across, ‘weapons and forced us to jump; says to provide medical, psychological, and 23-year-old Somali man who humanitarian assistance to these Boats made to hold a maximum of 30 survived the violent journey that migrants, refugees, and asylum {040 people are crammed with 100 (0 ended with at least 29 people dead seekers. A network of people in the 120 people, sometimes more. To keep _ on Seplember 9 this year. “We were passengers from moving, smugglers 120 people, overcrowded. The trip “In order to intimidate us, they beat them with sticks, belt buckles, took two days. We did not receive beat us heavily with their belts. or knives. “We have lot of patients food or water. Some of us were placed One of the smugglers threw petrol with very deep cuts, sometimes on the in the hull, Several people died on us and showed off his lighter.” hea, sometimes on the arms," says because of asphyxia; some others: Doctors Without Borders/Médecins Sans Frontiares (MSF) head of mis 'lom Reyes ans migrants rom Somalis an thoi ered onthrein Vern nt year: Yemen 2007 SSF e SITUATION REPORT - YEMENMIGRATION AND SMUGGLER ROUTES TO YEMEN souce:unncr YEMEN ERITREA Aiknarae Aden ETHIOPIA ‘communities along the 170-mile coast alert MSE when the boats arrive. Mobile teams are then sent to the coast to provide emergency medical and ps and water, and kits with clothing and toiletries. MSF has provided assistance to over 3,800 people so far this year. AN ACT OF DESPERATION ‘Yemen has long been a country of orgin, destination, and transit for ret- lugees and migrants because ofits proximity to the Horn of Africa and the wealthy Gulf states. Yemen itself, however, is the poorest country in the Arabian Peninsula and is struggling with deop poverty, unemployment, rapid population growth, and dwin- dling water resources. MSF provides ‘medical care to people in the north, of the country, which Is gripped by fighting between government troops land the Al Houthi rebel movement. Lacking safe and legal alternatives to leave their countries, refugees and migrants must use smugglers to cross the Gulf of Aden. Despite the known, dangers of the trip, the numbers of SITUATION REPORT- YEMEN Cou of Aden Difbouti ferbera . reo SOMALIA \_ Tarcowe Indian Ocean those risking thelr lives to get to Yemen is increasing as more peaple flee the escalation of the conflict in Somalia and the drought affecting the Horn of Africa, During the first five ‘months of 2008, more than 20,000 people arrived by sea in Yemen, more than double the number for the same period last year, and 400 people had died or were missing, aceording to the UN High Commissioner for Refugees (UNIICR), The actual number of casualties is likely higher, as many bodies lost at Sea are never found. “We were expecting a massive arrival of refugees and migrants: ‘the 2008 figures are double those of 2007. But itis clearly net only the numbers that are increasing: the violence has tripled since the beginning of September.” This year, several boats arrived with passengers who had not been beaten, which gave Verdd’s team some hope, Bue that changed when MSF teams witnessed the 29 dead bodies washed upon the beach at Wadi Al-Barak in September. Survivors of the journey said 10 more people had died during the trip, “The horrific cases of 2007 are being repeated again,” says Verdi “People have been through terrible things. One woman lost her three young children, A young Ethiopian witnessed his 70-year-old father being thrown into the sea at night and only recovered his dead body the next morning,” he says. “We were expecting a massive arrival of refugees and migrants the 2008 figures are double those of 2007, But itis clearly not only the numbers that are increasing: the violence has tripled since the beginning of September.” HELPING NEW ARRIVALS. In April, MSF opened a medical facility in anew UNHCR reception center in the coastal town of Ahwar. Migrants stay at the reception center for a few days to recuperate from their journey. MSF gives them basic medical and psychological assistance, and they are fered by UNHCR before being taken to the Kharaz Refugee Camp. About two-thirds of arrivals are ‘Somalis; one-third Ethiopians, Yemen has been welcoming to Somalis, re- cognizing them as prima facie refugees, which means they don't have to make ‘acase for why they fled their troubled home country. Ethiopians that survive the crossing, however, face more chal- lenges: they are considered illegal and are subject to deportation without regard to asylum claims. MSF is urging the international com- munity to do more to protect the migrants, refugees, and asylum seekers who arrive in Yemen and (o provide ‘more support. “To date, the humanitar- {an response has been inadequate,” Verdi says. *More international assis- tance is urgently needed and donor countries should commit themselves politically and financially”toa of 86 dead bodies washed up onsore on December 12 let year Only about 50 people suived tht crossing, which started at wth ‘snestimate 10 passengers Yemen 2007 CSF [An MSF sta member administer fst sid toa Soma refuge who nde on the shoes of Ymen. Yorn, 2007 © MSFTreating Women and Girls with Fistulas {n 2007 a group of 11 women suffering from vesico-vaginal (VV) fistulas approached MSF nurse Esther Moring and her medical team in eastern Chad, asking for treatment, At that time, Moring’s team was focused on performing war surgery, and the only MSF fistula project in Chad was in Bongor three days’ drive to the other side ofthe country. Te sole Chadian surgeon treating fistula was Located inthe capital, N'Djamena, ard limited funds meant he could perform no ‘more than one repair per month, with a yearlong waiting lst. norte to help those women and countless others with fistulas in eastern Chad, Moring and an MSP team initiated a pilot fistula surgery program based in the town of Abéché, near the border with Darfur, Sudan, In January 2008, the program began admitting patients, including Sudanese refugees «and Chultan women displaced by the ongoing Darfur conflict. These women are living, {in some of the most vulnerable conditions with ltd, if any, access to medical care. Here, Moring describes what fistulas are and why starting this project was so important, In Anéché, a woman undergoes surgery for ful. Chad 2008 © Caude Maheudenu/ USF VVF is an abnormal opening between the vagina and bladder or the vagina and rectum, through which urine or foces leak continually, It’s usually a consequence of prolonged, obstructed labor where the baby cannot exit the ‘womb, either because it’s in the wrong position or because the head of the baby is simply too big to pass through, the mother's pelvis. Usually, a woman, develops a fistula trying for many hours, or days, to push the baby out, and the condition frequently accurs among young and adolescent girls be- ‘cause the gir’s body Is too young and small to deliver the baby. In the developed world, women experiencing these complications will havea C-seetion before it gets to the point where a fistula could occur. But {in sub-Saharan Africa, usually, the baby will die during labor, before thebirth, and the mother will often die from complications such as sepsis or hemorrhage relating to a ruptured ‘uterus, a life-threatening tear in the ‘Womb, due to the obstructed and prolonged labor. Ifthe mother survives the prolonged labor, she is very likely to have a fistula from the relentless pressure of the baby's head during labor. It is thought that for every woman with such a fistula birth injury, up to eight others will have died during obstructed labor. In addition to incontinence, there are other serious health issues that come with fistula, including neurological problems that make it difficult to walk, skin ulcerations caused by the continual leaking, renal infections, land major psycho-social problems stemming from the reactions of people around her to the smell caused by continual incontinence. Surviving. ‘means, in addition to the physical pain and burden of fistula, the woman will have an extremely hard life, as she will often be shunned by her own society and rejected by her husband. She may be completely Isolated and have to beg for food, She \ill be unable to carry out normal activities such as going to the market, \wouldings or the mosque or ehurch with other women. PREVENTION OF FISTULA Fistulas are preventable, but it requires skilled and trained birth attendants to follow pregnancies and detect prob- Jems early on and emergency obstetric care such as a C-section when neces sary. Many women in sub-Saharan Africa have little or no access to such services. Births are traditionally at home with untrained people, and even when health care is available nearby, social mores can take precedence over the health of the mother, Often the traditional birth attendant, ‘or member of the family or community responsible for helping to deliver the baby, either doesn’t think of going to a hospital or doesn't have the resources to pay for the ride there. In some parts of the region, custom requires a male elder to approve surgery, and medical professionals can meet with strong resistance, even when a woman is experiencing intense pain and suffering and even when her life is in danger. A large number of those who die from ‘obstructed labor or who survive with fistulas are between the ages of 10 and 18 and are of small stature. They might have been made to marry and become pregnant quite young, and because their bodies have not fully developed, they cannot deliver the baby. These are the women and girls, who are at risk of such complications, and huge numbers of them die. As the fistula program in Abéché grows, it will havea focus on prevention through training and outreach to traditional birth attendants and local ‘community and religious leaders~as ‘well as concentrate on (raining Chadian health care staff in fistula prevention and management, BEYOND THE OPERATION Treating women with fistulas involves, ‘much more than an operation. When ‘women arrive for treatment, they can be in very bad shape anemic, mal- PATIENT STORY: ZENEBA nourished, and psychologically trauma- tized. It may take weeks in a hospital for them to get healthy enough to ‘undergo fistula repair. Post-operative recovery takes about three weeks, and close, meticulous care is very important because if the first attempt at repair does not work, subsequent attempts are much harder, Recovery presents new challenges for the patient, both physical and other- wise. She must relearn how to control her bladder; and she also must find a way to reintegrate into society, return to her community and explain what happened to her, as well as develop a way to be self-sufficient. This could ‘mean learning haw to read and write, or learning a handicraft some way to earn fan income. The program plans to help patients recover in this way, as well. After a woman leaves the facility, strict precautions must be taken in order for her to fully recover. She should not get pregnant for six months, and MSF provides contraception for that time period. But ifshe does become pregnant, she absolutely must have a C-section in aa hospital, Otherwise, a new obstruction during labor could be fatal, or it could fend in more serious tears. It is difficult {or staff to monitor a woman’s progress after she leaves the facility, and the insecurity of eastern Chad! makes it that ‘muuch more difficult. So MSF is working, with Chadian health care partners on finding new ways todo this. Zeneba martied very young, which is common in this part of the world, and became pregnant when she was barely 15 years old, Her delivery was overseen by a traditional midi it lasted five days and the child was stillborn, She came to MSF's fistula repair hospital in Abéché to receive help. “Lhad never been to a health center before giving birth,” she said, “The hospital was very far away, and it was certainly very expensive. My husband wouldn't have wanted to go there.” FIELD JOURNAL ~ EASTERN CHADTaking the Plunge: Pooling Patents Could Help Get Urgently Needed New Medicines A patent sharing scheme that helped the United States build planes during World War I now could help drug ‘manufacturers create new, urgently needed medicines. When legal wrangling between patent holders of various aircraft components looked like i¢ would permanently ground US planes by brining manufacturing to a halt, just as the United States was preparing to enter the war, Congress pushed through the creation of a patent pool. The pool worked by placing all aircraft patents under the control of a new association, and manufacturers licensed. ‘he patents for a fee, which was pald to the original patent holders. The United States got its planes. Now UNITAID', ‘he International drug purchase facility, is taking up the same concept as a way to break down barriers to medical innovation and deliver the treatments that MSF patients ‘and others in developing countries urgently need. One example of how a patent pool for medicines could ‘make a huge difference is in treating children living with HI, Ann, a 15-year-old MSF patient in Thailand, tells her story: “Tyas 10 years oli when I started taking antiretrovirals (ARV). [weighed just 11 kilograms (39 pounds). [had t0 take medication for TB and HIV at the same time, There ‘were so many pills around 18 tablets a day that it was almost impossible to swallow them all. I was so sick I couldn't ‘move, I couldn't eat, and my lips were stuck together. My mother used to sit with me for ages, getting me to swallow the pills one by one with glasses of water. Fortunately, I need to swallow far fewer pills now, but [still don’t like it If could talk to someone who makes the medicine I would ask if it could be just one tablet, ewice a day.” ‘Since she first started taking ARVs, part of Ann’s wish has ‘come true: there is now one pill for children that combines ‘Above: oi hing wth HV propares nerds regime in rachomblo prone ‘rales 2008 © Joann Hong / MSFthree anti-AIDS drugs in one tablet ina fixed-dose combi- nation, which is used by many MSF projects. But children living with BIV have different needs and require different formulations, and this single option is not a solution. The vast majority of HIV-infected children are still left without proper treatment. Instead, their caregivers have to split up adult tablets or grind them into powder to try to roughly approximate a child's dosage of ARVs clearly a risky business. The problem is that making fixed-dose combination ARVs for children has not been a priority for most pharmaceutical companies. They make their money in industrialized countries where there are barely any children living with HIV anymore so there's no market argument to develop the products. As wel, to come up with a pill combining two or three component drugs, a manufacturer would have to negotiate with all the separate patent holders a potentially horrendously lengthy legal process even ifthe parties were willing to negotiate. So that’s why the simplicity of the UNITALD proposal has been causing some excitement in the public health commu- nity. This is how it works: under a voluntary agreement, the holders of individual drug patents put their patents into, ‘pool. Then, the administrators of the pool license the use of the patents to any interested producers on payment ofa royalty, which goes back to the original patent holder. There's still work to be done on the terms of the licenses for Instance, where the products can he sold and which diseases can be treated but since the negotiations with patent hole ers, license-fssuing, and royalty payments are all carried ‘out under one roof, the hope is that this streamlined process, \will encourage multiple drug developers to take the plunge. Another advantage will be the reduction in the cost of medi- cines, as Ellen 'Hoen, director of policy and advocacy at MSF's Campaign for Acooss to Essential Medicines, expla Today, when you're faced with a patent in a country, as a generic producer you have to wait 20 years until the patent term runs out, With a patent pool you can speed that up because as soon as the patent is in the pool, the generic ‘company ean go to the pool, pay the royalties, and develop ‘a generic version of the product so you will get competition ‘much earlier, and competition fs the single most important force that drives drug prices down.” The benefits of this scheme aren’t restricted to helping develop new medicines for children, It ould also generate affordable, newer fixed-dose combination drugs for adults ‘who need them, At the moment, the prices of new drugs are just too high. For instance, MSF pays between $613 and $81,022 for the newer World Health Organization (WHO)- ‘recommended regimen for first-line AIDS treatment-a 7-10 12-fold increase compared to older first-line treatments, ‘which are now available for $87 per patient per year. But if the patents for these new drugs were put into the patent pool, the situation could be transformed as generic and other manufacturers come forward to develop new products. That's why many donors and public health experts are behind the idea of the patent pool; hey recognize that Jong-term treatment for HIV/AIDS cannot be supplied with- ‘out major changes in the way we access medicines, Asa voluntary Initiative, the buy-in from pharmaceutical ‘companies is critical. So far, reaction from the industry ‘has been cautiously positive. The main body, the Inter- ational Federation of Pharmaceutical Manufacturers and Associations, has called the idea “very interesting,” and individual companies have also said they would be willing {consider licensing patents to the pool depending on the nature of the licensing terms. T'Hoen is optimistic about the future of the patent pool ‘She says it's also very important that generic drug producing ‘companies come forward to show their Support for the idea. If it takes off, she says, the pool could bring huge benefits to both MSF patients and millions of other people in devel- oping countries In need of new and affordable treatments, “Ithink if the UNITAID patent pool succeeds, the effects ‘could be really phenomenal, both in the area of access, ‘namely bringing prices down, and in the area of developing, osporately noeded combinations and pediatric formulations, But success will depend on everybody collaborating” Find out more about the work of MSF's Access ‘Campaign at msfaccess.org; and go to doctorswithoutborders.org/alert to find out more about UNITAID and the patent pool initiative. "UNITAD is anintemationl drug purchase ait hat brings together 27 coun ol ght hve ile ieee: HIV/AIDS, malar ad tubercui “he project wae started by France, ral, Chil Nara, athe United ‘ing, adits members se macy Arean counties where tose aseases are most prevalent ‘CAMPAIGN FOR ACCESS TO ESSENTIAL MEDICINES@DOCTORSWITHOUTBORDERS.ORG MSF TREATS MALNUTRITION IN SOUTHERN ETHIOPIA See video showing MSE operations inside a nutritional center in the Oromiya region of southern Ethiopia, where MSF began responding to a malnutrition crisis in May, NO CHOICE: SOMALI AND ETHIOPIAN REFUGEES, ASYLUM- SEEKERS, AND MIGRANTS CROSSING THE GULF OF ADEN Read an in-depth report featuring testimonies taken from survivors of the illegal crossing and information from the MSF staff who have assisted them. A REFUGEE CAMP IN THE HEART OF THE CITY This Fall, MSF brings its traveling refugee camp exhibit to eight cities in Canada and California, The tour will wrap up in San Diego on November 9, but will ive on online. Visit the Tour Blog, featuring video of the tours and interviews with visitors and special guests in each city, as well as written entries from MSF fleld workers. (ON THE MEDICAL FRONT “Assessing Antimalarial Efficacy in a Time of Change to Artemisinin-Based Combination Therapies: The Role of Médecins Sans Frontldres,” a recent article published in the journal PLoS Medicine, discusses MSF" role in conducting ‘much-needed research studies on the effectiveness of newer drugs to treat malaria, It also addresses the subsequent effect of these field data on Influencing national policy changes to artemisinin-based combination therapy (ACT) drugs. This article and others published in medical and scientific journals are archived on our MSF Field Research site \S00CTORSWITHOUTBORDERS.ORG ove: Meco 2008 MSF opis 2008 Susan Sanaor/ SF PODCASTS MSF at the International AIDS Conference, September 2008 In this special MSF Frontline Report, listen to stories from the 17th Inter- national AIDS Conference in Mexico. This August, MSF presented medical data from its HIV/AIDS projects around the world and discussed challenges to providing the best care, You'l hear about two key issues: the shortage of health workers in sub-Saharan Africa thats helping to keep the 70 percent of people living with HIV from receiving tne care they desperately need; and the challenges to treating children with HIV. SLIDESHOW Refugees and Migrants Risk ‘Their Lives to Cross the Gulf of ‘Aden to Yemen Thousands of people risk their lives, every year crossing the Gulf of Aden to escape from conflict, violence, drought and poverty. During 2007, almost 30,000 took the dangerous voyage to seek relative safety in Yemen. These photos show people who arrived on the southern Yemen coast in 2007 and MSF providing assistance to them. This year’s peak time for smugglers crossing the Gulf of Aden began in September and continues into October, due to climate and water conditions.UPCOMING EVENTS & FUNDRAISING NEWS MSF FEATURED IN “BATTLE IN SEATTLE" FILM The film “Battle in Seattle”, which ‘opened in theaters in September, dramatizes MSF's advocacy effort at ‘the World Trade Organtzation’s (WTO) 1999 ministerial meeting in Seattle. While recounting the protests at the WTO meeting, it also describes the actions of Dr. Bernard Pécou!, then director of MSF's Campaign for Access to Essential Medicines, who urged the WTO to prioritize public health when regulating trade of essential medicines for diseases such as HIV/AIDS, malaria, and sleeping sickness. The cast includes Charlize Theron, Woody Harrelson, and Ray Liotta. More information Is at battleinseattlemov IN 2008 DOCTORS WITHOUT BORDERS MEDICAL TEAMS. RESPONDED TO AN UNPRECEDENTED NUMBER OF CRISES This past year has been an extraordinary year for emergency response, and our medical teams plan to continue to respond where the humanitarian needs are greatest in 2009 and beyond, Natural disas- ters, food crises, and the long.term needs of our pationts with HIV/AIDS and other diseases are not going to 0 away overnight, and we need your support more than ever to continue to deliver livesaving emergency care. MSF recognizes these are extraordi= nary economic times. Asa strong STRENGTHEN YOUR COMMITMENT MSF would like to thank all of our donors who have pledged to our Maltiyear Initiative. With their annual ‘commitments of $5,000 or more, these generous supporters provide MSF with predictable and sustainable funds, enabling us to respond effectively and rapidly to emergencies around the World and helping us to better plan for the future, To date, we have received pledges totaling $18,716,625 towards the initiative. To find out how you can pledge a gift over a three-to five- ‘year period of time, please contact Mary Sexton, director of major gifts, at (212) 655-9781. supporter of MSF's work, please renew vyour giving so that we can enter 2009 Knowing that the organization can ‘continue our lifesaving work, respond- ing immediately and effectively where people need us the most. Rode Sherbet, plays x Mar, a character based on Or. Benard cou foxmer decor of MSF Compsin for Acces to Ese Macc, Baars Tyson i lye Annan the th "Batle insente” ® UPCOMING EVENTS & FUNDRAISING NEWS.Vereo 2008: Marcel Nimfuehe/ MSF In August, MSF presented medical data from its HIV/AIDS treatment programsaround the worldat the 17th International AIDS Conference: (IAC) in Mexico City. MSF experts and staff hosted press con- ferences and panel discussions on the challenges of treating children with AIDS and the potential benefits of a patent pool for medicines proposed by UNITAID. MSF also led “Mind the Gaps,” a special session on the critical shortage of health care workers in sub-Saharan Africa, Speakers gave presentations on how an exodus of health workers is affecting people living with HIV and the health care system. 2399 Seventh Avenue, 2nd Floor New York,NY 10001-5008 ‘ek 212 679 6800 Fox: 212 679 7016 Wworw-doctorsuithoutborders.org “tis ing to stand by and watch people growing sicker-and sometimes dying~as they wait weeks and even months before being treated simply because there are nat enough health care workers,” sald Dr. Mit Philips of MSF. Near the end of the IAC, health workers and organizations, including MSF, initiated a spirited rally to express the need for more health professionals in these countries. You can watch the rally and view medical presentations, research papers, interviews with MSF staff, and photos on MSF's Mexico 2008 IAC mini-website, at doctorswithoutborders.org/mexicoaidsconference2008/. 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